Whither indigenous medicine
Picture this: Vigyan Bhawan, New Delhi, the House of Science in the capital. Two blue panels proclaim the coming together of government and industry; the prime minister addresses a gathering of 1500 people, in which he is welcomed with the blowing of a conch shell and gifted a bel plant for good health and well-being. Naturopathy inspired snacks are served to the guests (with a back-up of the usual chai and samosa); presentations are made from laptops onto projection screens; and the chairman of the Council for Scientific and Industrial Research (CSIR) delivers the keynote address. So what’s brewing? A conference on the challenges to Indian systems of medicine and homoeopathy, appropriately titled Good Health in the Millennium! As an advance publicity report put it, ‘Traditional medicine never had it so good.’
Represented at the conference was the government (by no less than the PM and a senior minister) and the representatives of industry (CII bosses alongwith their major sponsors) – both putting their weight behind a hitherto marginalised and languishing sector, that of the Indian systems of medicine and homoeopathy (ISM hereafter). Some days earlier, the government had upgraded the small division in the large Ministry for Health and Family Welfare responsible for ISM into a full-fledged department, complete with the post of secretary; it had also started a web page, signalling that this sector had definitely arrived.
These developments were meant to launch the ISM in both the public and private health arenas in a markedly different way, creating an impression that this sector, once on the margins, was now elbowing its way towards the centre. As the chairman of the CSIR remarked, if the world was going herbal, could India be far behind?
I argue here that this is a picture so carefully painted that the old print it glosses over could easily be missed. Indeed, India has been herbal, like other civilizations, for as long as we can remember. But from the end of the 19th century until well into the 20th, this reality was sought to be erased. The post-colonial nationalist rhetoric never fails to deride the colonial state’s policies and attitudes for ignoring the ISM, a claim supported by later research (Arnold 1994; Bala 1991). What is less realised is that the post-colonial Indian state too systematically marginalised the ISM for the better part of 50 years in ways that are explicated later.
Within the framework of the market, companies making traditional medicines were not only small but considered as encoding low prospects. What now appears like a reversal of that trend is not actually so. All that is new today is a rediscovery of the possibilities of going herbal, but on a different set of parameters. These parameters are being defined by the momentum and direction of the dominant economies of the world, in turn setting the frame which countries with old herbal traditions have now to follow. So if government and industry in our country seem to have suddenly woken up to the glories of herbalism, it is not out of some loyalty to indigeneity or tradition, but a level-headed recognition of its increased marketability particularly in the international economy.
To understand the process by which indigenous medicine is being located in the public health sector today and its continuing relevance, we need to appreciate three aspects of our development – the policy processes of the post-colonial Indian nation state, the market mechanics during the colonial and post-colonial periods, and the new dynamics of the international economy, in particular the response it is eliciting from both the Indian state and market.
Let me first deal with two preliminary questions. First, what is the Indian system of medicine? ISM is a term of bureaucratic convenience and includes Ayurveda, Unani, Siddha and Naturopathy, all ancient medical systems practiced in India. There are three characteristics of the ISM that set them apart from other traditional or folk medical systems. First, these systems have a textual tradition, evolved over many historical periods, which record both knowledge as well as practices. This sets them apart from many other ‘traditional’ or ‘folk’ medicine systems that exist in India and elsewhere. Unlike the others, ISM is well documented, verifiable for its authenticity and does not necessarily rely on oral traditions.
Second, unlike other textual traditions, ISM allows for plurality. The diversity of practice with respect to geography, topography and biodiversity within each tradition (particularly Ayurveda) is evident in the composition of these texts and demonstrates interesting localised pluralisms in otherwise canon-bound traditions. Third, the development of each specific system is profoundly influenced by the others, including the incorporation of new elements in pharmacology and diagnostic and treatment practices. Thus, while maintaining distinct identities, they are close in both orientation and practice. As argued later, this characteristic is often deliberately overlooked to score ideological points about the over-arching superiority of Ayurveda. This is one way the Hindu right attempts to establish the superiority of Hindu religion over others, because traditional systems of medicine are essentially cultural systems closely associated with the metaphysics of (usually) a specific religion.
The second question is, why should we bother about ISM? Collectively, ISM elicits a spectrum of reactions (from complete distrust to complete faith), inspired not only by an experience of these systems, but equally by the ideological hegemony of biomedicine since the colonial period. While statistics reveal that a majority of people use these systems rather than biomedicine, the reasons are quite complex. Often it is because they do not have access to biomedical facilities (research shows that a larger number of people would rather opt for biomedical treatment). At the same time, a considerable proportion of people trust the Indian systems, particularly from among the rural population. Much of the urban populace too turns to them when biomedicine fails.
Besides, India is one the richest regions in terms of its biodiversity, which constitutes the base of all the systems of medicine that have flourished here. Over centuries, a great fund of cognitive resource, knowledge base and skill has developed, with distinctive perspectives on the body and medical intervention. The equation of modern medicine with the knowledge and practice of medicine, reflects little more than sheer arrogance.
The web page of the department of ISM referred to earlier, claims, ‘As a matter of fact, ISM policy has been evolving gradually in response to widely varying socio-political situations and the changing health needs of the country (<www.nic.in/ismh> 1997).’ This is indeed ironic, for if there is something that the state has not done, it is precisely this.
Until the beginning of the planning period in the ’50s, there was a positive perception about the Indian systems among policy-makers – that the ISM had long been practiced by people in this country reflecting faith and belief; that its pharmacological basis lay in the rich biodiversity of the country, a factor which could help make medicinal formulations both cheap and easily accessible; even more that its emphasis was on ensuring a healthy lifestyle and prevention of disease. For all these reasons it was believed that these systems had the potential to provide a support base for public health in this country.
The Bhore and Chopra committees, both legacies of the colonial state, however suggested that modern medicine be given pride of place. In this way the new nation state could establish its scientific credentials by embarking on a health service based on the biomedical system developed in the West. At the same time, there were conflicts within the Congress between the powerful lobbies representing traditional and modern medicine (Brass 1972). Gandhi too would not allow a denial of the pride and faith that Indians felt in their indigenous systems of medicine. What emerged then was a compromise; a public health system based on both allopathy and the indigenous systems of medicine, but structured in a particular hierarchical order.
The major focus was on providing ‘modern medicine’ to a deprived Indian population while the indigenous systems were accorded their ‘rightful’ place by bringing them up to date with scientific developments. Given the overall commitment of the post-colonial Indian state to a ‘scientific temper’, the hegemonic relationship between allopathy and the others as the dominant ideological orientation of the state was established early on (Banerjee 1995: 130-147).
The marginalisation of the ISM was effected in three ways. First, the allocation of resources between allopathic and other systems was completely disproportionate. The total allocation was raised from Rs 35 crore last year to Rs 100 crore this year and this announcement drew applause from the starved ISM sector. But the not-so-fine print is that the total allocation for the Ministry of Health this year is Rs 4319 crore, and ISM gets a mere 2.5% of the whole! A clear reflection of the marginalisation of the Indian systems of medicine in the public health care system.
Second, there was an attempt to ‘translate’ these systems into methods of teaching, marketing and production followed in biomedicine, since the public health arena involved all three aspects. The argument advanced ad nauseam was that for these systems were to be taken as seriously as biomedicine, an equivalent five-year degree course, as comprehensive as the basic medical education required for a bachelor’s degree the world had come to recognise, needed to be fashioned. Equally, that mass produced indigenous medicines would have to be subjected to rigorous quality testing such that their ‘value’ could be established in terms understood by the pharmaceutical industry. This demanded a process of standardizing; though both the procedures of preparation and testing were already laid down in great detail in the texts and practices of yore, they needed to be ‘translated’ to contemporaneity. In state parlance, this meant constituting committees and inviting long depositions from different factions. The outcome: ambivalent results vis-ŕ-vis actual procedure, not to mention interminable delays.
The third strategy involved ‘replicating’ the apparatus of the dominant biomedical system in the Indian systems of medicine and homoeopathy. This not only meant hospitals, dispensaries and units manufacturing medicine, just as in the biomedical system, but also that the resource allocation would be in the same proportion. This meant foregrounding big, centralised health care centres or hospitals (necessarily implying a great deal of expenditure on a few institutions) at the expense of the smaller, basic and dispersed primary health care centres, accessible (by definition) to a large number of people.
Though designed to signal that the government treated all the systems at par, the process resulted in both the marginalisation of a decentralised system of health care and a sidelining the perspective of treatment in the Indian systems which is based on examining and treating a person in entirety rather than focusing on specific ailments. If only ISM could have become part of active health policy, it might have helped balance the excesses of the biomedical system (which too was being developed at the cost of its own epidemiological dimensions).
The market arena took cognisance of indigenous medicine systems during the colonial period itself. Medicines prepared on the basis of non-modern Indian systems first entered the modern market in the late 19th century. The challenge they faced was of both of form and content because the new medicines, though expensive, were easy-to-pop pills claiming miraculous results.
The USP of traditional medicines was that they were inexpensive as they were made of locally available natural materials. Besides they were familiar, as people had relied on them for long. ISM could thus claim greater legitimacy despite the advances reported by biomedicine, in turn leading to mass production of Ayurvedic and other medicines. The outcome was companies like Dabur and Arya Vaidya Sala Kottakkal. The results of modern mass production were manifold. In the modern context what is significant is that it helped structure the identity of both the medicines and the systems of which they were a part.
In the early phase of modernisation the distinct contribution of the market was in terms of two features of modern mass production – standardisation and commercialisation of medicines. Standardisation involved making medicines of uniform quality. While some standards were legal requirements laid down by governments, in the main they were based on the companies’ perceptions of what would increase their credibility in the market. Commercialisation involved three processes: packaging, positioning and advertising, just like for any other commodity in the modern market (for a detailed discussion, see Banerjee 1995: 158-180). In visible terms this meant that indigenous medicines were available in chemist shops that sold angrezi medicines, even in cities far away from the point of production. Also, that they were advertised in the media through wall writing, newspapers, pamphlets, even banners on elephants!
Their virtues could now be enunciated and comparisons made with biomedicine in the new language and mode of advertising. The most important benefit of mass production was, however, that of returns to scale. The expectation was that over time indigenous medicines would cost less, making them accessible to ordinary people.
But the last 100 years of mass production has seen more powerful and subtler developments. The institutional consolidation of the indigenous systems has, however, been fraught with controversy, resulting in a decline of the value of the systems qua systems. Though a larger number of people today use these medicines, fewer people now look for treatment in the Indian systems of medicine. Though apparantly improbable, this is a result of both a transformation of the medicines in themselves and their subsequent appropriation by allopaths. Companies began to produce medicines based on traditional formulations, but in the contemporary form of tablets, capsules and syrups. This adoption of a new form as also the fact that these medicines were now being tested in clinical trials similar to those involving biomedical formulations is what enabled companies to sell them to allopaths.
Allopaths were encouraged to use indigenous medicines to complement, rather than to substitute, their line of treatment. Considering that this permitted an appreciation of the value of biomedical treatment without disturbing its basics, it appealed to allopaths who used them with great success. And given that the allopathic practice of medicine was both more visible and powerful than the indigenous systems, the new form gained strength. This process is best described as pharmaceuticalisation, i.e., using the pharmacology of these systems to create new pharmaceuticals, or medicinal commodities, that could be sold independently of the original line of treatment (an idea hinted at in Nandy and Visvanathan 1990: 170).
In combination, the processes of standardisation, commercialisation and pharmaceuticalisation fostered by the market have substantially changed the profile of the ISM in the arena of health. We have here an apparent paradox. While these processes have conferred a new legitimacy on traditional systems, their radical transformation has meant that even as their face-value has appreciated, their innate importance as systems of healing has declined. Indigenous medicines manufactured in traditional ways and forms are usually expensive and not always trustworthy in the ingredients they use. No wonder, some of the most cherished dreams of the modernisation of the Indian systems of medicine remain unfulfilled. The medicines prepared in accordance with classical texts and procedures are not meant for the ordinary and the poor; those which are mass produced are affordable but rarely conform to the best standards.
The most damning impact has been on the role of ISM in public health. While the private market for ISM has expanded, its presence in the public health system has shrunk. The government has made no concerted attempt to ensure production of affordable, quality medicines to counter market trends.
In the last decade or so we can trace three developments which, though unrelated, have significantly affected the Indian medicine sector: (i) The Indian economy has changed tracks in terms of its orientation towards the international economy and has become ‘liberalised’. (ii) A new wave in the international economy, ‘globalisation’ in the shorthand of our times, has created a new trading regime, the World Trade Organisation. (iii) There is a renewed surge of interest in traditional/folk/indigenous peoples’ medicine in Europe and the United States. What is pertinent is that, unlike before, both state and market have responded positively and in tandem.
Adirect consequence is that the processes of standardisation, commercialisation and pharmaceuticalisation may take a different direction and orientation altogether. The growing interest in traditional medicine in the West has excited Indian manufacturers, who see in this a massive export potential. Given their long experience in manufacturing such medicines that are now suddenly in demand, this is not an unfair expectation. But the reality has proved otherwise.
The quality control requirements of both the European Union and the Food and Drug Administration of the United States are not easy to fulfil. They demand extensive clinical trials with large sample sizes, just as for all biomedical products. A big company like Dabur has conducted clinical trials on traditional medicines in traditional forms for many years now, while the Himalaya Drug Company has done the same for Ayurvedic proprietary medicines. But even for them, the requirements of successful operation in the western markets appear daunting.
However, there are better chances of selling herbal products as ‘food supplements’ and not as medicines since the law in this case is far less stringent. Also, this is a market big enough to attract Indian manufacturers. In the event, Indian companies could demonstrate great market potential and ability to become players in the ‘global’ context. In the current climate of liberalisation, this could not only get them incentives from the state, but enable them to claim that they were upholding the glory of Indian tradition!
Not that these companies will stop producing Ayurvedic medicines as such. But, as has been the trend for some time, they will increasingly concentrate on products which can be positioned, packaged and marketed in a specific way to meet the requirement of a new burgeoning consumer class that can both afford and sees value in traditional healing forms. The pharmaceutialisation process too will continue, though it would be subjected to continuous modification. An interesting extension of this concept, already underway, involves investments in health farms and luxury type health/holiday resorts.
Further, in anticipation of this new trend in European and American markets, many transnational pharmaceutical companies have opened up new divisions to create ‘herbal’ formulations. This has increased the demand for medicinal plants as raw material. There already exists an old and wide network of markets for medicinal plants in this country. Existing laws also require certain conditions of transportation and storage to be fulfilled before they are used to make medicines. In reality, however, the standardisation of raw materials has been a somewhat neglected sphere of activity. With independent potential being discovered in terms of an export market, a new dimension to standardisation has emerged. It does appear likely that investment in this part of the process would yield substantial returns, considering the growing demand for these products in the international market.
Both these developments link to what this paper began with – the new-found interest of the private sector in the Indian systems of medicine and the emerging tie-ups between government and industry, hitherto unheard of. Industry needs the government to set norms for production such that the definitions of proprietary medicine in ISM can be expanded to include food supplements as well and, of course, for export incentives. Second, it needs a regularisation of the medicinal plants market, so far completely informal, such that it becomes easier for local industry to meet global market standards. The government on the other hand is under pressure from the biodiversity conservation lobby to avert a continuous depletion of both the plant base as also the knowledge base. It also needs to identify new avenues to plug into the international economy. No wonder the prime minister announced the constitution of a Medicinal Plants Board (presumably a regulatory and scientific body) besides the already existing central scheme for development and cultivation of medicinal plants, expressing a clear intention to promote the interest of industry.
The poor hardly stand to gain from these developments. A primary achievement of the growth of the market is an extension of choice. But, by definition, this choice can be exercised only by those who are part of the market in the first place. The idea behind encouraging manufacturing companies to get into traditional medicines was to make them available at a low price to those who could not afford expensive modern medicines. The aim of the public health system was to extend the choice of alternatives to those who did not have any to begin with. Unfortunately, after fifty years, both the public health system and the market have failed a majority of people in the country.
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P. Brass, ‘The Politics of Ayurvedic Education: A Case Study of Revivalism and Modernisation in India’, in L.I. Rudolph and S.H. Rudolph, Politics and Education in India, Harvard University Press, Cambridge, 1972.
C. Leslie, Asian Medical Systems: A Comparative Study, University of California Press, Berkeley, 1976.
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A. Nandy and S. Visvanathan, ‘Modern Medicine and its Non-Modern Critics’, in F.A. Marglin and S. Marglin, Dominating Knowledge: Development, Culture and Resistance, Clarendon Press, Oxford, 1990.